Provider Demographics
NPI:1629664958
Name:BUDZICKI, KATHY L
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:L
Last Name:BUDZICKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7155 HART ST APT A1
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4936
Mailing Address - Country:US
Mailing Address - Phone:440-650-6770
Mailing Address - Fax:
Practice Address - Street 1:7155 HART ST APT A1
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4936
Practice Address - Country:US
Practice Address - Phone:440-650-6770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHM4301875Medicaid